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Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation
J S Plotkin1, V L Scott, A Pinna
1Department of Anesthesiology, University of Maryland Medical Center, Baltimore 21201-1595, USA.
Insights
Liver transplantation significantly increases risks for patients with coronary artery disease. Both medical and surgical management strategies show high morbidity and mortality, impacting candidacy decisions.
Area of Science:
- Cardiology
- Hepatology
- Transplantation Surgery
Background:
- Coronary artery disease (CAD) is a significant comorbidity in patients undergoing liver transplantation.
- The impact of pre-existing CAD on outcomes after liver transplantation requires careful evaluation.
Purpose of the Study:
- To assess perioperative and postoperative morbidity and mortality in liver transplant recipients with coronary artery disease.
- To compare outcomes based on the management strategy for coronary artery disease prior to transplantation.
Main Methods:
- Retrospective analysis of 32 patients with coronary artery disease who underwent liver transplantation (1990-1994).
- Evaluation of cardiac management (medical, angioplasty, surgical bypass grafting) and United Network for Organ Sharing (UNOS) functional status.
- Determination of perioperative and postoperative outcomes, including morbidity and mortality.
Main Results:
- Overall mortality was 50% and morbidity was 81% in patients with CAD undergoing liver transplantation.
- Medically managed CAD patients experienced 56% mortality and 100% morbidity.
- Patients with prior coronary artery bypass grafting (CABG) had 50% mortality and 80% morbidity; simultaneous CABG and liver transplant had high mortality.
Conclusions:
- Liver transplantation in patients with coronary artery disease is associated with significantly increased morbidity and mortality.
- Outcomes are similarly poor for both medically and surgically managed CAD patients.
- Increased perioperative and postoperative risks necessitate careful consideration for patient candidacy and informed consent.
Abstract:
Thirty-two patients with coronary artery disease who underwent liver transplantation between 1990 and 1994 were identified. Coronary artery disease was managed medically (n = 9), by angioplasty (n = 1), or surgically (n = 22) prior to liver transplantation. Two patients underwent simultaneous coronary artery bypass grafting and liver transplantation. Complete preoperative cardiac evaluation was performed in all patients. Perioperative and postoperative morbidity and mortality were retrospectively determined. Overall mortality was 50%, whereas morbidity was 81%. Follow-up was between 1 and 3 years after liver transplantation. Subgroup analysis revealed that medically managed patients had a 56% mortality and a 100% morbidity. The patient who underwent angioplasty survived without morbidity. One patient who underwent simultaneous coronary artery bypass grafting and liver transplantation died intraoperatively. The second patient survived but required pacemaker insertion and inotropic agents postoperatively. The 20 patients with prior coronary artery bypass grafting had a 50% mortality and 80% morbidity. Further, analysis by United Network for Organ Sharing functional status revealed a higher than expected mortality in all groups. The morbidity and mortality associated with liver transplantation is significantly increased in patients with coronary artery disease and is equally high in medically and surgically treated patients. By comparison, patients without coronary artery disease have a 3-year survival of 55.4% (status I) to 79.7% (status III and IV). The increased intraoperative and postoperative risk in patients with coronary artery disease undergoing liver transplantation should be considered when determining the candidacy of these patients as well as when providing informed consent.